How to help when smoking, alcohol complicate PTSD

WASHINGTON 
Reaching for a cigarette to cope with a flashback is all too common among sufferers of post-traumatic stress disorder. The nicotine hit may feel good but scientists say its brain action probably makes their PTSD worse in the long run.

Here's the rub: At least half of PTSD sufferers smoke, and others wind up dependent on alcohol, anti-anxiety pills, sometimes even illegal drugs. Yet too few clinics treat both PTSD and addictions at the same time, despite evidence they should.

Now studies are recruiting PTSD patients – from New England drug-treatment centers to veterans clinics in North Carolina and Washington – to determine what combination care works.

"It's kind of a clinical myth that you can only do one at a time or should only do one at a time," says Duke University PTSD specialist Dr. Jean Beckham, a psychologist at the Durham, N.C., Veterans Affairs Medical Center. "Everybody's afraid to have their patients quit smoking because they're afraid they're going to get worse. There's not a lot of empirical data about that."

And her research on how to break the nicotine-and-PTSD cycle raises a provocative question for a tobacco-prone military: Are people at higher risk of developing PTSD if they smoke before they experience the violent event or episode?

Post-traumatic stress disorder – which can include flashbacks, debilitating anxiety, irritability and insomnia – is thought to affect nearly 8 million Americans at any given time. Anyone can develop it after a terrifying experience, from a mugging to a hurricane, a car crash to child abuse. But PTSD is getting renewed attention because so many veterans returning from combat in Iraq and Afghanistan seem vulnerable. A study last year by the RAND Corp. research organization estimated nearly 20 percent of them, or 300,000 people, have symptoms of PTSD or major depression.

What's less discussed is that patients often don't realize they might have PTSD and try to relieve symptoms by self-medicating with alcohol, tobacco and other substance use – worsening habits that existed before the trauma or starting anew.

Addiction itself is a mental health disorder that causes changes in some of the same brain areas disrupted by mood and anxiety disorders like PTSD, says a new report on the co-illnesses from the National Institute on Drug Abuse. That argues for simultaneous treatment. Indeed, up to 60 percent of people in addiction treatment are estimated to have PTSD – although they seldom acknowledge symptoms – and they're three times more likely than other patients to drop out.

A handful of studies suggest combo care helps. One example: VA researchers in Connecticut gave the alcoholism drugs naltrexone and disulfiram to PTSD patients, and watched not only their drinking ease but their PTSD symptoms improve, too.

Then there's nicotine. It temporarily enhances attention when it hits the brain – one reason that members of military tell the VA's Beckham they smoke. Although PTSD patients say a cigarette helps their mood when they're having symptoms, the extra attention may be reinforcing bad memories.